Primary care physicians act as gatekeepers for patient referrals to specialist care, diagnosis and management advice, or when specialist procedures are needed. However, unexplained variations in referral rates by primary care physicians have been noted. Inappropriate referrals have negative implications for patients, for the costs of care and for healthcare systems. This summary describes the evidence on interventions to improve referrals from primary care to secondary care.

Key messages

Professional education that includes guidelines, checklists, video materials and educational outreach by specialists probably improve the quantity and quality of referrals.

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Background

Primary care providers make decisions about which patients to refer to specialists for advice on diagnosis or management, and for specialised procedures and care. However, evidence suggests that such referral processes could be improved. Some patients may be referred inappropriately or they may not be referred when they ought to be; others are referred for unnecessary tests or procedures.

A previous systematic review by Grimshaw (1998) found relatively little research evaluating interventions to improve referral behaviour. Several subsequent studies have been completed, and the summary presented here is based on an update of Akbari et al’s review in which the effectiveness of interventions to improve referrals from primary care to specialist care was assessed.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

17 studies were found, of which 9 evaluated professional educational interventions, 4 evaluated organisational interventions, and 4 evaluated financial interventions. Of the 17 studies identified, 10 were randomised trials, 1 was a nonrandomised trial, 5 were controlled before-after studies, and 1 was an interrupted time series study.

Participants

Primary care physicians, including general practitioners, family doctors, family physicians, family practitioners, and other physicians working in primary healthcare settings, who fulfil primary healthcare tasks.

Specialist physicians working in hospitals or community outpatient settings.

Primary care physicians and specialist physicians.

Settings

Primary care and hospitals.

12 of the studies were located in the UK, 2 in the USA, and 1 each in the Netherlands, Palestine, and Finland.

Interventions included: the passive dissemination of local specialist referral guidelines; the dissemination of referral guidelines using structured referral sheets (using checklists designed to be completed at the point of referral as a way to prompt primary care physicians about the key elements of their own pre-referral investigations and patient management); and secondary care, provider-led, educational strategies.

The passive dissemination of referral guidelines and checklists probably results in little or no improvement in the quantity or quality of referrals. The certainty of this evidence is moderate.

The combination of referral guidelines and structured checklists, together with video materials or educational outreach, probably improves referral rates, referral appropriateness, and pre-referral patient management by primary care physicians. The certainty of this evidence is moderate.

Referral guidelines with structured referral sheets probably result in little or no change in patient outcomes. The certainty of this evidence is moderate.

Joint primary care practitioner and consultant sessions probably result in improved patient outcomes. The certainty of this evidence is moderate.

A multi-faceted intervention including guidelines, education, referral sheets, new staff and equipment changes, resulted in a 50% referral reduction (1 study). Referral guidelines, structured referral sheets, educational meetings, and open-access investigations for the assessment of urological conditions resulted in no differences in number of primary care consultations, but reduced waiting times for first specialist appointments (Ratio of means of waiting times: 0.7, 95% CI 0.55 to 0.89) and increased the probability of a management decision being reached after one hospital appointment (OR 5.8; 95%CI 2.9 to 11.5)(1 study).

Moderate

Appropriateness of referrals

The use of a checklist and video by general practitioners probably improves referral appropriateness (1 study). Educational outreach led by secondary care providers probably improves referral appropriateness for specialised investigations of dyspepsia (1 study). Passive guideline dissemination, with or without outreach, probably leads to little or no difference in referral appropriateness for tracer conditions (1 study).

Moderate

Patient management

Passive guideline dissemination, with or without outreach, probably leads to little or no difference in hospital patient management of tracer conditions (1 study). Referral guidelines together with structured referral sheets probably improve pre-referral assessments and management of fertility problems by primary care practitioners (2 studies); this form of intervention also resulted in improved compliance with urological referral guidelines, and reduced waiting times for hospital outpatient appointments (1 study). Educational outreach by secondary care providers resulted in no changes in the number of investigations of orthopaedic patients, but did result in an increase in the use of injection therapy by primary care practitioners (30.6% study vs. 11.7% control, p<0.001) (1 study).

Moderate

Patient outcomes

Referral guidelines with structured referral sheets resulted in little or no change in patient outcomes for urological conditions at 12 months (1 study). Joint primary care practitioner and orthopaedic consultant sessions resulted in an increase in patients who were disorder-free after a year (35.7% study vs. 23.7% control, p<0.05) (1 study).

Moderate

GRADE: GRADE Working Group grades of evidence (see above and last page)

2) Organisational interventions

Organisational interventions include changes in who delivers healthcare, and how such care is organised or delivered. Four studies evaluated the effects of organisational changes on referrals to secondary care. These included an evaluation of physician disciplines (for example, whether the physicians were trained in family medicine or internal medicine), the provision of physiotherapy services in primary care, obtaining a second opinion in-house on referrals, and providing appointment slots within secondary care services in proportion to the size of the referring primary practice.

The provision of physiotherapy services at the primary care level may decrease the number of referrals to orthopaedic and rheumatology specialist services. The certainty of this evidence is low.

Second opinions in-house may reduce referral rates and improve referral appropriateness. The certainty of this evidence is low.

Dedicated appointment slots at secondary levels for each primary care practice may decrease referral rates to specialist care. The certainty of this evidence is low.

Practices in which physicians are trained in family medicine compared to practices in which physicians are trained in internal medicine may result in a reduction in referrals and fewer visits to acute and emergency care. The certainty of this evidence is low.

GRADE: GRADE Working Group grades of evidence (see above and last page)

3) Financial interventions

Four studies evaluated financial interventions: these included changes in provider remuneration, participation in fundholding schemes (UK National Health Service), and charging patients equivalent rates for being seen by a private specialist as by a hospital-based specialist. The certainty of the evidence provided by these studies was very low.

The effects of financial interventions on referral rates are uncertain. The certainty of this evidence is very low.

Relevance of the review for low-income countries

Findings

Interpretation*

APPLICABILITY

Most of the included studies were conducted in high-income countries and within particular health systems. These system included, for example, the publicly funded National Health System in the UK, and Medicaid in the USA.

The studies were based in well-resourced environments in which primary care services were provided by an adequate number of practitioners, and relatively easy access was available to specialist services. Such scenarios are not necessarily available or possible in many low-income countries. The study findings therefore need to be interpreted with caution when applied to low-income countries.

EQUITY

The studies were based largely in urban settings, in populations with relative equity in health and access to health care.

The interventions may increase inequity if they are not applied or adapted to populations in rural or remote areas or if there are substantial socio-economic variations or discrepancies amongst those receiving the intervention.

ECONOMIC CONSIDERATIONS

Costings were included in several studies but full economic evaluations were seldom reported.

Limited information is available on the cost-effectivenes of the interventions. Local costings should therefore be undertaken, particularly in settings differing from the original investigations.

MONITORING & EVALUATION

Studies were conducted over relatively short time periods (a maximum, for example, of two years), and in health systems in high-income countries. The studies focused on the measurement of process outcomes; very few studies assessed patients’ health outcomes.

Any interventions implemented based on the review findings should include a monitoring component to assess theperformance of the intervention within the context. Evaluations should measure the appropriateness of the referrals, not only the number of referrals. Patient outcomes should also be considered.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see: http://www.supportsummaries.org/methods

NorthStar – How to design and evaluate quality improvement interventions in healthcare: NorthStar is a tool providing a range of information, checklists, examples and tools based on current research on how best to design and evaluate quality improvement interventions. www.rebeqi.org/?pageID=36&ItemID=18

Dudley LD, Pantoia T. Do educational, organisational or financial interventions improve referrals from primary to secondary care? A SUPPORT Summary of a systematic review. August 2016. www.supportsummaries.org

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org